Febrile Seizures in the ED: Hot and Bothered

-Case-

It’s late at night when the parents of a 2-year-old boy rush him into the ED. He had a fever earlier in the evening, and while they were getting him ready for bed, he suddenly stiffened, his eyes rolled back, and he started convulsing. It lasted about two minutes before stopping on its own. Now, he is postictal but slowly perking up. 

• Key Red Flags to Consider: is this a seizure disorder vs meningitis vs intracranial pathology, or is it simply a febrile seizure?

-Evaluation-

• Febrile seizures are the most common seizure disorder in kids (2-5%), typically occurring in children in ages 6 months – 5 years
• Types:
  • Simple: Generalized, <15 min, no recurrence in 24 hours → Benign, no ↑ epilepsy risk
  • Complex: >15 min, focal, or recurrent within 24 hours → Requires further evaluation
• When do we worry?
  • Prolonged seizure (>5 min)
  • Child outside the classic age range
  • Focal deficits present on exam
  • Persistent altered mental status
  • Concern for a CNS infection? Consider LP, neuroimaging, EEG!

-Management-

• Simple febrile seizures:
  • Parental reassurance (this presentation is both benign and self-limiting!)
  • Treat fever source (commonly an otitis media, or viral illness)
  • Antipyretics (comfort measure only; unfortunately this does not prevent seizures)
• Complex febrile seizures:
  • Consider admission + further workup to rule out infection, structural abnormality
  • Abortive therapy is needed for prolonged seizures; benzos are key if the seizure lasts >5 min!

-Fast Facts-

• Classic presentation of a febrile seizure = fever + brief, generalized seizure in child aged 6 months – 5 years
• Minimal workup needed if reassuring history & normal exam
• Antipyretics do not prevent seizures
• Parental education is crucial; calm their fears and emphasize the benign nature!

Febrile seizures are more alarming for parents than for the child. Not every febrile seizure needs an extensive workup; sometimes, the best medicine is education and reassurance!

Want to learn more? Read our in-depth febrile seizures study guide on this topic!

Cheers,

Tamir Zitelny, MD